Diagnostic precision in proximal penile fracture: the use of MRI and the perineal approach

A man in his 30s reported severe penile pain after vigorous sexual activity, described as a 'popping' sound followed by partial loss of erection and pain. Initial examination revealed significant scrotal swelling and bruising without evidence of a typical eggplant deformity.1 However, the treating practitioner did not recognize a potential penile fracture. An ultrasound was performed a week later due to ongoing symptoms and suggested a possible penile fracture or hematoma (Fig. 1). Given the delayed presentation and unclear history and exam findings, magnetic resonance imaging (MRI) was subsequently performed after referral to a tertiary centre.2, 3 MRI identified a 2.5 mm proximal right corpus cavernosum defect with an associated hematoma (Fig. 2). The patient then underwent urgent operative management.3-5 A flexible cystoscopy was performed to rule out a concomitant urethral injury. A midline perineal approach was used to access the proximal defect (Fig. 3). The surrounding hematoma was evacuated, and the defect was closed with 3–0 PDS interrupted sutures. The patient recovered well and returned to normal pre-injury erectile function at 6 weeks. MRI has been known for its superior utility in providing detailed visualization of soft tissues. It is a superior imaging modality compared to ultrasound in diagnosing penile fractures, with improved specificity and sensitivity.6 The effectiveness and accuracy of MRI have been recently demonstrated in the Australian setting.7 However, its application in diagnosing penile fractures has been limited.8 The main barriers to the widespread use of MRI to diagnose penile fracture are cost and availability. There is no specified MBS rebate for MRI, but the estimated cost would be between 350 and 500 AUD, compared with ~$100 for the US. MRI is also limited in its availability, especially in emergency and rural settings. Sometimes, this could delay definitive management, leading to poorer patient outcomes. Delayed presentation or management can increase complication rates, especially after 24 h.5 In this scenario, the ultrasound provided an initial hint but was non-definitive. The MRI confirmed the fracture and pinpointed its precise location and extent. The perineal surgical approach chosen for treating this fracture enabled efficient access to the root of the penis. Comparatively, a circumferential sub-coronal degloving incision is the typical approach. It has the advantage of excellent exposure, especially if multiple injuries or concomitant urethral injuries are suspected. However, this approach may lead to more complications, including decreased sensation, oedema, infection, and skin necrosis, thought to be secondary to the additional trauma.9 Although the perineal approach has only been reported a few times in the literature, this method has proven particularly effective for proximal injuries.8 This approach obviates the need for a degloving manoeuvre, as the defect has already been identified with imaging. The theorized benefits include decreased oedema, faster return to sexual function, and decreased risk of operative complications.10 While ultrasounds are frequently used to diagnose penile shaft fractures, this case underscores the superior diagnostic accuracy of MRI, especially for proximal fractures. Moreover, the perineal surgical approach, tailored for such proximal injuries, was pivotal for a successful repair. In suspected proximal penile fractures, an MRI can offer a level of precision unmatched by traditional ultrasound methods. Furthermore, adopting a perineal approach for surgical repair can ensure effective treatment and optimal recovery. Patient consent has been obtained for the publication of these images. Open access publishing facilitated by The University of Newcastle, as part of the Wiley - The University of Newcastle agreement via the Council of Australian University Librarians. Benjamin C. Buckland: Conceptualization; investigation; writing – original draft; writing – review and editing. Bridget Heijkoop: Conceptualization; supervision; validation; writing – review and editing. Jaw Tronidjaja: Conceptualization; resources; supervision; writing – review and editing. Peter G. Chong: Conceptualization; supervision; writing – review and editing.